Patient intervention: poisoning and overdose emergencies

By Cristiano Antonino On Jan 10, 2023

Poisoning and overdose are among the 10 most common emergencies responded to by emergency room professionals, accounting for about 3.5% of all calls to the emergency number in Western countries

What are poisoning and overdose?

Poisoning occurs when a person takes or is exposed to a substance that is harmful to health or that can cause death.

This can include drugs.

Despite child-resistant packaging and dose limits per container, poisoning is still a serious danger for both children and adults.

According to the National Capital Poison Center, in 2019 most poisonings (76.6%) in the US were unintentional, 18.9% intentional, and 2.6% adverse reactions.

In children under the age of six, 99.2% of poisonings are unintentional, compared to 33.8% of teen poisonings and 60.8% of adult poisonings.

An overdose is a type of poisoning in which a person takes an excessive amount of any drug, whether prescribed, over-the-counter, legal or illegal.

The severity of an overdose depends on the drug, the amount taken and the physical and medical history of the person who took it.

Acute poisoning consists of exposure to the poison once over a short period of time.

Symptoms develop depending on the degree of exposure.

Systemic poisoning is poison that circulates throughout the body, usually after absorption.

In contrast, substances that destroy tissue but do not absorb into the bloodstream, such as caustic soda, are considered corrosives rather than poisons.

Many common household drugs are not labelled with the image of a skull and crossbones, even though they can cause serious illness or even death.

Chronic poisoning is repeated or continuous long-term exposure to a poison, where symptoms do not occur immediately or after each exposure.

The patient becomes ill gradually or becomes ill after a long period.

Chronic poisoning most commonly occurs after exposure to poisons that bioaccumulate or gradually accumulate in the body over time.

Poisons such as mercury, gadolinium and lead bioaccumulate.

Most biocides, including pesticides, act as poisons to target organisms, although less observable chronic poisoning can also occur in non-target organisms, such as people applying biocides.

Many substances that are considered poisons are only indirectly toxic.

For example, ‘wood alcohol’ or menthol is not a poison per se, but is chemically converted to toxic formaldehyde and formic acid in the liver.

Many drug molecules are made toxic by the liver, and the genetic variability of certain liver enzymes means that the toxicity of many compounds differs between individuals.

Poisoning should not be confused with envenomation, which occurs when an animal injects poison into a person.

Envenomation is a special type of poison that requires the victim to be injured for the poison to enter the bloodstream. Ultimately, the most effective treatment for poison is the right antivenom.

Risk factors for drug overdose

Improper storage of drugs: improperly stored drugs can be an easy target for young children, who are curious and tend to put things in their mouths.

It is easy for children to come into contact and accidentally overdose on drugs that are not properly sealed and stored away from them.

Not knowing or following dosage instructions: Even adults can overdose on drugs if they do not follow instructions.

Accidentally taking too much of the drug or taking doses earlier than directed can easily lead to an overdose of an otherwise safe drug.

History of abuse or dependence: Intentional misuse of prescribed drugs or use of illicit drugs can put you at risk of overdose, especially if you abuse often or become dependent.

The risk increases if one uses several drugs, mixes different drugs or uses them with alcohol.

History of mental disorders: Mental disorders may also be risk factors for an overdose. Depression and suicidal thoughts can be triggers for an overdose, especially if these symptoms are not treated.

Signs and symptoms of poisoning

The effects of poisoning depend on the substance, the amount and the type of contact.

Age, weight and state of health also influence the symptoms.

The following are common signs and symptoms of poisoning:

Nausea and vomiting
Diarrhoea
rash
Redness or sores around the mouth
Dry mouth
Drooling or foaming at the mouth
Difficulty breathing
Dilated (larger than normal) or constricted (smaller than normal) pupils
Confusion
Fainting
Tremors or convulsions

Signs and symptoms of drug overdose

The symptoms of a drug overdose can vary depending on the person, the drug and the amount taken.

However, universal symptoms of an overdose include:

Nausea and vomiting
Drowsiness
Loss of consciousness
Difficulty breathing
Difficulty walking
Agitation
Aggressiveness or violence
Enlarged pupils
Tremors
Convulsions
Hallucinations or delusions

Causes of poisoning and overdose

Most common sources of poisoning in children (<6 years)

Cosmetics and personal care products
Cleaning substances
Analgesics
Foreign bodies/toys/etc.
Food/herbal/homeopathic supplements
Antihistamines
Topical preparations
Vitamins
Pesticides
Plants
Most common sources of poisoning in adults (≥20 years)
Analgesics
Sedatives/Hypnotics/Antipsychotics
Antidepressants
Cardiovascular drugs
Cleaning substances (household)
Alcohols
Anticonvulsants
Antihistamines
Pesticides
Hormones and hormone agonists

When to call the Emergency Number in case of poisoning

If you suspect that someone has been exposed to a poison or has overdosed, you must act quickly.

If it is a serious or life-threatening condition, call the Emergency Number immediately for emergency medical treatment. Otherwise, you can call the poison control service, which will provide you with information and assistance.

If you do not know the substance involved, call the Emergency Number.

Here are some tips to help inform the Emergency Number:

Look for signs to identify poison: spills, smells, stains, changes in behaviour, empty containers.
Take the bottle or container with you to the telephone.
Look in the victim’s mouth for compresses, dust, discolouration, cuts, burns or odours.
Rinse and clean the child’s mouth. Keep the poisoned child within reach. You will be asked some questions about the child’s appearance and behaviour.

What to tell the receptionist

If possible, collect the following information for the dispatcher:

Information about the substance and the label
Age and weight of the victim
Existing health conditions or problems
First aid already given
Whether or not the person has vomited
Location and distance to the nearest hospital.
How the substance entered the body (inhalation, ingestion, dermal absorption, etc.).
How to treat poisoning

Below are guidelines for the treatment of various types of poisoning:

For poisons taken internally (ingestion):

Look into the victim’s mouth and remove all tablets, powder or any material present.
Examine the mouth for cuts, burns, swelling, unusual colouring or odour.
Rinse and clean the mouth with a cloth.
Call the Emergency Number and follow the operator’s advice.

For poisons on the skin:

Brush off all dry poisons and flood affected areas with large amounts of plain water.
Wash the skin with soap and water and rinse.
Remove and discard all affected clothing.
If a serious medical condition is suspected, call the Emergency Number immediately

For poisons in the eyes:

Hold the eyelid open and drip room temperature water or normal saline solution over the bridge of the nose for 15 minutes.
If the victim is a small child, wrap him/her in a towel (with arms placed at the sides under the towel) and place him/her on a flat surface or chair so that he/she can be safely controlled.
Do not try to hold the child under the tap, in the shower or bathtub. Do not use pressurised water.
Do not allow the victim to rub his or her eyes. Do not use medicated drops, such as Visine.
If a serious medical condition is suspected, immediately call the Emergency Number

How US rescuers and paramedics treat poisonings and overdoses

In the event of a poisoning or overdose, a paramedic or EMT will likely be the first health care provider to assess and treat your condition.

Paramedics have a well-defined set of protocols and procedures to follow for most emergencies they encounter.

For all suspected poisonings, the first step is a rapid and systematic assessment of the patient.

For this assessment, most rescuers use the ABCDE approach.

ABCDE stands for Airway, Breathing, Circulation, Disability, and Exposure.

The ABCDE approach is applicable in all clinical emergencies for immediate assessment and treatment.

It can be used on the street with or without equipment.

It can also be used in a more advanced form where emergency medical services are available, including emergency rooms, hospitals or intensive care units.

Poisoning and overdose, treatment guidelines and resources for US medical first responders

Poisoning and overdose treatment guidelines can be found on page 225 of the National Association of EMT Officials’ National Model EMS Clinical Guidelines (NASEMSO).

NASEMSO maintains these guidelines to facilitate clinical guidelines, protocols, and operating procedures for state and local EMS systems.

These guidelines are evidence-based or consensus-based and have been formatted for use by practitioners.

The guidelines include the following assessment:

Ensure that the scene is safe. If possible, use an environmental carbon monoxide (CO) detector on the ‘first in’ bag.
Consider body substance isolation (BSI) or appropriate PPE.
Assess ABCD and, if indicated, expose the patient for assessment and then re-cover to ensure preservation of body heat.
Vital signs, including temperature
Connect a cardiac monitor and examine the rhythm strip for arrhythmias (consider 12-lead EKG).
Check blood glucose levels
Monitor pulse oximetry and ETCO2 to check for respiratory decompensation.
Perform device evaluation for carboxyhaemoglobin, if available.
If indicated, identify specific drugs taken (including immediate-release and sustained-release drugs), time of ingestion, dose and quantity. If appropriate, bring all drugs (prescribed and non-prescribed) into the environment.

Obtain an accurate ingestion history (as the patient may lose consciousness before arrival at the emergency department):

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Time of ingestion
Route of exposure
Amount of drug or toxin ingested (safely collect all possible drugs or agents)
Alcohol or other intoxicants taken
If you carry an exposure agent, consider the threat to yourself and the facility.
Obtain relevant cardiovascular history and other prescribed medications.

Check for signs of needles, paraphernalia, bites, bottles or traces of agents involved in the exposure, self-inflicted injuries or trauma.

Law enforcement should have checked for weapons and drugs, but you may decide to check again.

Obtain the patient’s relevant medical history.

Perform the physical test.

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EMS protocol for poisoning and overdose emergencies

Protocols for pre-hospital treatment of poisoning and overdose vary from one EMS operator to another and may also depend on the patient’s symptoms or history.

Below is an example of a pre-hospital treatment protocol for poisoning and overdose:

Performing initial treatment / Universal patient care protocol
Routes:

Ingested poisons:

Protect the respiratory tract.

DO NOT induce vomiting.

Transport patient with all containers, bottles and substance labels if it is safe to do so.

Inhaled poisons:

Remove from hazardous environment immediately.

Maintain airway and support breathing.

Transport patient with all containers, bottles and labels of the substance if it is safe to do so.

Absorbed poisons:

Remove poison following the procedures outlined in the Burn Protocol.

Transport patient with all containers, bottles and substance labels if safe to do so.

Injected poisons:

See guidelines for treatment of specific substances.

Once decontamination procedures have been completed, do not delay transport.
Determine the following:

What?

When?

How much?

Over what period of time?

Were actions taken by bystanders, family members and the patient prior to the arrival of EMS?

Overdose / Ingestion of toxic substances / Poisoning emergencies:

Alcohol:

Alcohol-related emergencies can range from acute intoxication to alcohol withdrawal and delirium tremens (DT).

Assess the patient and follow the appropriate protocol for medical management according to the clinical presentation.

Consider hypoglycaemia. Perform a rapid glucose determination. If glucose is <60 mg/dL or clinical signs and symptoms indicate hypoglycaemia, refer to the Diabetic Emergencies Protocol.

For signs and symptoms of hypovolemic shock or dehydration, follow the protocol for hypoperfusion shock.

For convulsions due to alcohol withdrawal, refer to the Convulsions Protocol.

Narcotics/ Opiates:

Support breathing, if necessary, with an artificial respiration mask and supplemental O2. Postpone testing of advanced airway management until after administration of Naloxone if ventilation with BVM is adequate.

Consider hypoglycaemia. Perform a rapid glucose determination. If glucose is <60 mg/dL or clinical signs and symptoms indicate hypoglycaemia, refer to the protocol on diabetic emergencies.

In case of suspected narcotic overdose complicated by respiratory depression: Administer Naloxone (Narcan®) 1 mg IM (anterior lateral thigh). If the patient shows no signs of improvement (adequate respiratory response/increased LOC), administer an additional 1 mg IM within 10 minutes. If Naloxone cannot be administered IM, administer 2 mg intranasally (IN) via atomiser. If the patient does not show signs of improvement (adequate respiratory response/increased LOC), administer a further 2 mg IN and seek ALS support.

Tricyclic antidepressants:

Support breathing, if necessary, with an artificial breathing mask and O2 supplementation. (Tricyclic antidepressants include: Amitriptyline (Elavil®), Doxepin (Sinequan®, Adepin®), Imipramine (Tofranil®).

Cholinergics:

Support respirations, if necessary, with an artificial respiratory mask and supplemental O2. (Pesticides (organophosphates, carbamates) and nerve gases (Sarin, Soman) are the most common exposures.

Calcium channel blockers:

Support respirations, if necessary, with a breathing mask and supplemental O2.

Beta-blockers:

Administer oxygen via a non-rebreather mask at 12-15 lpm, as needed, and support respirations with a BVM.

Stimulants:

Assess the patient and follow the appropriate protocol for medical management based on clinical presentation.

Support respirations, if necessary, with a BVM and supplemental O2.

Severe signs and symptoms (convulsions, tachydemias): For severely agitated or combative patients follow the protocol for behavioural emergencies.

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